Beyond Diagnosis service request form

Self Help UK in partnership with Macmillan deliver a project offering emotional and practical support to people affected by cancer across Nottinghamshire.

The project can offer practical or emotional support. A client will be contacted by the project within 7 working days of this form being received.

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Client details

This service is requested for

Address

Telephone

Date of birth

Cancer diagnosis or carer

Cancer diagnosis/family member or carer?

Further information regarding the cancer diagnosis involved

What support is required and what benefit would a volunteer provide?

Are any other social care agencies involved?

Yes/No/Unsure?

Further information regarding other social care agencies

Who is involved?

Any other relevant medical conditions

Known risks

Are there any known risks e.g. history of aggression or violence?

Pets

Are there any pets within the household?

Self-referral

Yes/No?

Name of referrer

Referrer telephone

Email

Relationship to person service is for

I can confirm that the individual being referred has given their consent for their information to be passed on to the Macmillan Beyond Diagnosis Service and that they are happy to be contacted.

Submit